STATEMENT OF RECOVERY OR RETURN TO WORK

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1 STATEMENT OF RECOVERY OR RETURN TO WORK DISABILITY INCOME CLAIM INSTRUCTIONS (PLEASE DETACH THIS NOTICE BEFORE MAILING AND KEEP FOR FUTURE REFERENCE) Please answer all questions on the Member Statement on your Disability Income claim form Please provide a complete the List of Providers/Hospitals that have treated you for this disability. Date and sign both the Members Statement and the Authorization for Release of Information. Please have your Medical Provider complete both pages of the Medical Provider s Statement. Please see that the completed form is returned to: If you recover or return to work, please notify Pearl Carroll & Associates immediately by completing and mailing this statement to the above address. If you have any questions concerning your request for Disability Income benefits, you may call the Office of the Administrator at The fax number is Please note that we will not confirm receipt of a fax for hours. Mailing Social Security No.: - - Policy G I recovered: I returned to work Date: Month/Day/Year Other (I.E. Returned to work light duty, another job etc): Date: Signature:

2 CSEA MEMBER S DISABILITY INCOME FORM Member Date of Birth: Social Security # Female Male Mailing (No.) (Street) (Apt No.) (City or Town) (State) (Zip Code) Telephone No.: Home: ( ) Employer ( ) Height: Weight Employer s Normal Number of Hours Worked Per Week: Employer s Street (No.) (Street) (City or Town) (State) (Zip Code) What is the nature of your disability? Is disability work related? Yes No If yes, please attach a copy of the Employee Accident Report signed by manager Is disability due to an Injury? Yes No If Yes, when? / / Mo. Day Year Where did it happen? How did it happen? Date first treated for this disability: / / Mo. Day Year Date First Unable to Work: / / Date Last Worked: / / Mo. Day Year Mo. Day Year Have you attempted to return to your occupation since the date disability began? (If so, give details) If returned to work or recovered, give date: / / Returned to work: Full Time: Mo. Day Year Part Time: If Part Time, # of hours per day If not returned, when do you expect to? / / Mo. Day Year Are your working a second job? If so, please provide the name and address of the company and the hours you are working. **If disability is due to a Motor Vehicle Accident, please attach MV-104A Police Report** ** If treated in hospital or Urgent Care Center, please attach a copy of your discharge papers** 1

3 CSEA MEMBER S DISABILITY INCOME FORM Member s Name Member s Social Security # Names and addresses of providers consulted and any other providers seen for treatment. PLEASE PRINT If you need more space, you may attach a sheet of paper with the additional names, addresses, and phone numbers. Be sure to include all providers, as any missing may delay your claim. PHYSICIANS: HOSPITALS PHARMACIES 2

4 CSEA MEMBER S DISABILITY INCOME FORM Member Name Member s Social Security # Please state your occupation: **Please attach a copy of your official job description** Please fully describe all the duties of your occupation at the time you stopped working including the percentage of time spent on each activity: What are your daily activities? Are you receiving or will you be eligible to receive benefits from: Workman s Compensation? Yes No Pension Plan? Yes No Another Group Insurance Plan? Yes No Individual Disability Income Policy? Yes No Social Security Disability? Yes No If Yes insert policy number, claim number and address of insurance company or organization providing such benefits and amount of payment. Policy No. Claim No. Name and Address Amount of Payment I declare that the answers on Page 1, Page 2 and Page 3 of this form are complete and true to the best of my knowledge and belief. I also agree that I will advise the New York Life Insurance Company of my return to any type of work and that I will return any payments to which I am not entitled by reason of my return to work or termination of my disability. PLEASE NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION Date: MO/ DAY/YEAR Member s Signature The Member or someone on his/her behalf must sign here and on the Authorization for Release of Information Form. Please see that the completed form is returned to: Fax #

5 Release From: Authorization for Release of Information TO: All providers of medical services and supplies, pharmacy related service organizations, prescription history database suppliers, employers, insurance institutions, the Social Security Administration and other organizations. I authorize release to New York Life Insurance Company or their representative,, any independent claim administrators, consulting health professionals, pharmacy related service organizations and utilization review organizations with whom New York Life has contracted, information concerning health care advice, treatment or supplies provided the patient (including that related to mental illness and/or AIDS/ARC/HIV) and prescription records. This information will be used to evaluate claims for benefits. In Oklahoma, the information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease. This authorization may be used for a period of 24 months from the date signed below unless sooner revoked. I may revoke this authorization at any time by notifying New York Life in writing at the address given on this form. My revocation will not be effective to the extent New York Life or any other person has already disclosed or collected information or taken other action in reliance on it. The information New York Life obtains through this authorization may become subject to further disclosure. For example, New York Life may be required to provide it to an insurance regulatory or other government agency. In this case, the information may no longer be protected by the rules governing this authorization. A photocopy of this authorization and request form shall be as valid as the original. I know that I may request a copy of this authorization. Patient s Signature Print Name Date Social Security No Address City, State Zip Address Phone Number Medical Records Release to: Keais Records Service Inc Lamar, Suite 300 Houston, TX Please see that the completed form is returned to: Fax #

6 MEDICAL PROVIDER S STATEMENT (The patient is responsible for the completion of this form without expense to the Company) Notice to Provider: Thank you in advance for your cooperation in completing this form on behalf of your patient identified below. We will consider this information in conjunction with other information gathered to determine the claimant s eligibility for benefits according to his or her specific contract with us. We will periodically request that you provide updated information, records and chart notes to enable our evaluation of a continuing claim. In order for us to expedite our consideration of your patient s claim, please fully answer each question and sign and date the form where indicated. 1. PATIENT S NAME: SOCIAL SECURITY NO.: (First) (Middle) (Last) DATE OF BIRTH: / / 2. CURRENT MEDICAL CONDITION(s): PRIMARY DIAGNOSIS: SECONDARY DIAGNOSIS: ICD-9 CM CODE: ICD-9 CM CODE: 3. DATE THAT SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED: / / 4. DATE THAT PATIENT FIRST CONSULTED YOU FOR THIS CONDITION: / / 5. DATE YOU LAST TREATED THE PATIENT: / / 6. IS THIS CONDITION RELATED TO PATIENT S EMPLOYMENT? YES NO 7. WAS PATIENT REFERRED TO YOU BY ANOTHER PRACTITIONER? YES NO (If Yes, please provide the name and address of that practitioner): 8. OBJECTIVE FINDINGS (Include x-rays, lab results and clinical findings. If pregnancy, also give LMP and EDC): 9. HAS PATIENT BEEN HOSPITALIZED? YES NO (If YES, provide reason, hospital name and dates of confinement): 10. NATURE OF TREATMENT CURRENTLY BEING PROVIDED OR PLANNED: (Include dates and type of surgery and any medications prescribed if applicable): 11. HAVE YOU REFERRED THE PATIENT TO ANOTHER PRACTITIONER? YES NO (If Yes, please provide the name and address of all applicable physicians or ): 12. IN YOUR OPINION IS THE PATIENT ABLE TO WORK AT THIS TIME? YES NO IF NO, WHEN DO YOU EXPECT THAT THE PATIENT WILL BE ABLE TO PERFORM SOME WORK? / / 1

7 MEDICAL PROVIDER S STATEMENT PATIENT S NAME: SOCIAL SECURITY NO.: (First) (Middle) (Last) 13. IS THERE ANY TYPE OF JOB MODIFICATION OR ACCOMODATION THAT WOULD ENABLE THE PATIENT TO WORK AT THIS TIME? YES NO (If Yes, please describe): 14. BASED ON OBJECTIVE FINDINGS AND YOUR MEDICAL OPINION: a) THE PATIENT WAS TOTALLY DISABLED FROM: / / THROUGH: / / b) THE PATIENT WAS PARTIALLY DISABLED FROM: / / THROUGH: / / 15. LIST ALL CURRENT RESTRICTIONS AND LIMITATIONS YOU HAVE PLACED ON THE ATIENT S WORK AND PERSONAL ACTIVITIES DUE TO HIS OR HER MEDICAL CONDITION (If none, indicate NONE): 16. HAS THE PATIENT BEEN RELEASED FROM YOUR CARE? YES NO IF YES DATE RELEASED FROM YOUR CARE: IF NO, DATE OF NEXT SCHEDULED TREATMENT OR EVALUATION: / / / / ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES MEDICAL PROVIDER S DECLARATION AND SIGNATURE I declare that the answers on this statement are complete and true to the best of my knowledge and belief. I understand that periodic updates (including providing copies of medical records when requested) will be required in the event of a continuing claim. PROVIDER S NAME (PLEASE PRINT) Specialty TELEPHONE NUMBER STREET ADDRESS CITY STATE ZIP CODE PROVIDER S SIGNATURE DATE SIGNED Please return completed forms to: Fax #

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